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Chronological Changes in Appendiceal Pathology Among Patients Who Underwent Appendectomy for Suspected Acute Appendicitis. World J Surg 2021; 44:2965-2973. [PMID: 32322937 DOI: 10.1007/s00268-020-05509-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Given recent advances in imaging and the development of diagnostic parameters, the rate of unnecessary appendectomy (i.e., negative appendectomy) has been decreasing. However, the incidence of acute appendicitis (AA) in elderly patients is rising due to the aging of society. We aimed to identify chronological changes in demographics and appendiceal pathology among patients who underwent appendectomy for suspected AA. METHODS Data from 881 patients who underwent appendectomy for suspected AA between January 2006 and December 2017 were analyzed. The final diagnosis was based on intraoperative findings, pathological reports, and clinical course. Negative appendectomy was defined as the absence of appendiceal diseases including inflammation, fibrosis, and neoplasm. We compared demographics and appendiceal pathology between early (2006-2011) and late study phases (2012-2017). RESULTS The mean age of patients with pathologically proven AA (n = 761) was significantly greater in the late phase than in the early phase (38.6 ± 19.8 years vs. 44.0 ± 20.3 years, p = 0.0002), and the ratio of patients with AA aged ≧ 75 years was also increased (from 5.6 to 8.6%, p = 0.1120). The incidences of complicated appendicitis (defined as perforated or gangrenous appendicitis) and appendiceal diverticulitis (AD) were increased in the late phase compared to those in the early phase (61.3% vs. 77.2% and 3.7% vs. 6.6%, respectively). The negative appendectomy rate was significantly reduced in the late phase compared to that in the early phase (10.0% vs. 2.5%, p < 0.0001). CONCLUSIONS During a 12-year period, the mean age of patients with AA and the incidences of complicated appendicitis and AD increased, whereas the negative appendectomy rate decreased.
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Pearcy C, Almahmoud K, Jackson T, Hartline C, Cahill A, Spence L, Kim D, Olatubosun O, Todd SR, Campion EM, Burlew CC, Regner J, Frazee R, Michaels D, Dissanaike S, Stewart C, Foley N, Nelson P, Agrawal V, Truitt MS. Risky business? Investigating outcomes of patients undergoing urgent laparoscopic appendectomy on antithrombotic therapy. Am J Surg 2017; 214:1012-1015. [PMID: 28982518 DOI: 10.1016/j.amjsurg.2017.08.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/31/2017] [Accepted: 08/08/2017] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population. METHODS From 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI - Surgical Site Infection, DSI - Deep Space Infection, and OSI - Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality. RESULTS Out of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls. CONCLUSIONS Our analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy.
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Affiliation(s)
- Christopher Pearcy
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Khalid Almahmoud
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Theresa Jackson
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Cassie Hartline
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Anthony Cahill
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Lara Spence
- Department of Graduate Medical Education, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Dennis Kim
- Department of Graduate Medical Education, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Oluwabukola Olatubosun
- Department of Graduate Medical Education, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - S Rob Todd
- Department of Graduate Medical Education, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric M Campion
- Department of Graduate Medical Education, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Clay Cothren Burlew
- Department of Graduate Medical Education, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Justin Regner
- Department of Graduate Medical Education, Department of Surgery, Baylor Scott and White Health - Central Texas, Temple, TX, USA
| | - Richard Frazee
- Department of Graduate Medical Education, Department of Surgery, Baylor Scott and White Health - Central Texas, Temple, TX, USA
| | - David Michaels
- Department of Graduate Medical Education, Department of Surgery, Texas Tech Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Graduate Medical Education, Department of Surgery, Texas Tech Health Sciences Center, Lubbock, TX, USA
| | - Collin Stewart
- Department of Graduate Medical Education, Department of Surgery, University of Nevada - Mountain View Surgery Residency, Las Vegas, NV, USA
| | - Neal Foley
- Department of Graduate Medical Education, Department of Surgery, University of Nevada - Mountain View Surgery Residency, Las Vegas, NV, USA
| | - Paul Nelson
- Department of Graduate Medical Education, Department of Surgery, University of Nevada - Mountain View Surgery Residency, Las Vegas, NV, USA
| | - Vaidehi Agrawal
- Clinical Research Institution, Methodist Dallas Health System, Dallas, TX, USA
| | - Michael S Truitt
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA.
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Jurkovich GJ, Davis KA, Burlew CC, Dente CJ, Galante JM, Goodwin JS, Joseph B, de Moya M, Becher RD, Pandit V. Acute care surgery: An evolving paradigm. Curr Probl Surg 2017; 54:364-395. [PMID: 28756821 DOI: 10.1067/j.cpsurg.2017.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | - Kimberly A Davis
- Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO
| | - Christopher J Dente
- Department of Surgery, Emory University at Grady Memorial Hospital, Atlanta, GA
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ
| | - Marc de Moya
- Chief of the Division of Trauma, Critical Care, and Acute Care Surgery, Medical College of Wisconsin, Milwaukee
| | - Robert D Becher
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Viraj Pandit
- Department of Surgery, The University of Arizona, Tucson, AZ
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Factors Associated with Perforated Appendicitis in Elderly Patients in a Tertiary Care Hospital. Surg Res Pract 2015; 2015:847681. [PMID: 26380377 PMCID: PMC4561309 DOI: 10.1155/2015/847681] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/03/2015] [Accepted: 08/10/2015] [Indexed: 12/15/2022] Open
Abstract
Background. The incidence of perforated appendicitis in elderly patients is high and carries increased morbidity and mortality rates. The aim of this study was to identify risk factors of perforation in elderly patients who presented with clinical of acute appendicitis. Methods. This was a retrospective study, reviewing medical records of patients over the age of 60 years who had a confirmed diagnosis of acute appendicitis. Patients were classified into two groups: those with perforated appendicitis and those with nonperforated appendicitis. Demographic data, clinical presentations, and laboratory analysis were compared. Results. Of the 206 acute appendicitis patients over the age of 60 years, perforated appendicitis was found in 106 (50%) patients. The four factors which predicted appendiceal rupture were as follows: male; duration of pain in preadmission period; fever (>38°C); and anorexia. The overall complication rate was 34% in the perforation group and 12.6% in the nonperforation group. Conclusions. The incidence of perforated appendicitis in elderly patients was higher in males and those who had certain clinical features such as fever and anorexia. Duration of pain in the preadmission period was also an important factor in appendiceal rupture. Early diagnosis may decrease the incidence of perforated appendicitis in elderly patients.
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Segev L, Keidar A, Schrier I, Rayman S, Wasserberg N, Sadot E. Acute appendicitis in the elderly in the twenty-first century. J Gastrointest Surg 2015; 19:730-5. [PMID: 25681217 DOI: 10.1007/s11605-014-2716-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/27/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence of appendicitis in the elderly has risen. Older age is an independent predictor of poor surgical outcome. Herein, we present the most comprehensive single institution study to describe the natural history and outcome of appendicitis in elderly patients. METHODS A review of 1898 consecutive patients who underwent appendectomy between 2004 and 2007 was performed. The elderly patients were defined as older than 68 years. RESULTS The median age of the entire cohort was 25 years, and 55% were males. The elderly group included 68 patients (3.6%). On comparison by age, the elderly group had a significantly longer delay from symptom onset to admission (50 vs. 31 h, P = 0.01) and from admission to surgery, a longer operative time and hospital stay, and higher rates of postoperative complications and complicated appendicitis. CONCLUSION The current study demonstrated several unique characteristics of the elderly population with acute appendicitis, which include poor outcome and longer time intervals to diagnosis and treatment. In order to improve the poor outcome of the elderly population with appendicitis, prospective trials are necessary.
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Affiliation(s)
- Lior Segev
- Department of Surgery, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Acute appendicitis in the elderly: risk factors for perforation. World J Emerg Surg 2014; 9:6. [PMID: 24428909 PMCID: PMC3896723 DOI: 10.1186/1749-7922-9-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/13/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis. METHODOLOGY The medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier. RESULTS During the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient's pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group. CONCLUSION Acute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.
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Hornby ST, Shahtahmassebi G, Lynch S, Ladwa N, Stell DA. Delay to surgery does not influence the pathological outcome of acute appendicitis. Scand J Surg 2013; 103:5-11. [PMID: 24345979 DOI: 10.1177/1457496913495474] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Emergency surgery is performed on patients with appendicitis in the belief that inflammation of the appendix may progress to necrosis and perforation. Many cases of appendicitis, however, resolve with conservative treatment, and necrotic appendicitis may represent a different disease rather than the end result of inflammation of the appendix. We wished to explore the relationship between the interval to surgery after admission to hospital with appendicitis and the proportion of patients developing necrosis. METHODS Appendicectomy operations performed between 2005 and 2010 were reviewed. End points included age, sex, interval from admission to surgery, and final pathological diagnosis. RESULTS A total of 2403 evaluable patients were identified (1266 females). Necrotic appendicitis occurred more commonly in children (17.5%) and the elderly (25.4%) compared with adults (10.5%). The median interval to surgery of patients with normal histology (17.1 h) was longer than the time to removal of inflamed (13 h) or necrotic (13.5 h) appendices (p < 0.001).The ratio of necrotic to inflamed appendicitis in the entire cohort was 0.24. Multivariate analysis reveals that necrosis of the appendix is more common in children and the elderly and that the proportion of patients with necrosis does not change with increasing interval to surgery. DISCUSSION Our observations show that appendicitis is not more likely to lead to perforation if a short delay prior to surgery is allowed. In addition, our findings add weight to the increasing volume of data showing that necrosis of the appendix is a disease different from simple inflammation.
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Affiliation(s)
- S T Hornby
- Department of Surgery, Derriford Hospital, Plymouth, UK
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Lee JF, Leow CK, Lau WY. Appendicitis in the elderly. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 2000; 70:593-6. [PMID: 10945554 DOI: 10.1046/j.1440-1622.2000.01905.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Acute appendicitis in the elderly (i.e. those over 60 years of age) is associated with high morbidity and mortality rates. The present retrospective study reviews 10 years ( 1986-1996) of experience and outcome in treating acute appendicitis in patients aged 60 or above. METHODS One hundred and thirty patients with acute appendicitis were identified and their case notes reviewed. RESULTS Acute appendicitis was diagnosed at admission in 84 patients (64.6%). The remaining patients were observed for a median duration of 9.4 h prior to diagnosis and treatment. Patients with an underlying perforated acute appendix had a significantly longer period of pain prior to admission (P = 0.029; Mann-Whitney U-test) but perforation per se was not associated with a significantly higher rate of morbidity and longer length of hospital stay. In contrast, the use of midline or paramedian incisions was associated with a higher wound infection rate (P=0.003; Pearson chi-squared test) and a longer hospital stay (P<0.001; Mann Whitney U-test). None of the patients were subsequently found to have an underlying colonic neoplasm. The overall morbidity rate was 28%. The mortality rate was 2.3% and all three patients who died had a severe comorbid medical condition prior to developing acute appendicitis. CONCLUSIONS Acute appendicitis in the elderly is still associated with significant morbidity. But once acute appendicitis is diagnosed, then expedient surgery, appropriate use of perioperative antibiotics and a right lower quadrant incision can help to minimize the morbidity. Pre-existing severe comorbid medical condition(s) is a major contributory factor to mortality in these patients.
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Affiliation(s)
- J F Lee
- Chinese University of Hong Kong, Department of Surgery, Prince of Wales Hospital, Shatin, Hong Kong
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Abstract
Appendicitis is a common surgical disease that often presents with vague, inconclusive symptoms. Despite the development of technologically advanced diagnostic modalities, perforation has usually occurred before the surgeon sees the patient. Morbidity, length of stay, and hospital costs associated with appendiceal perforation have not changed markedly in the past 50 years. To evaluate prognostic markers for severe appendicitis, we reviewed 18 years’ worth of records of patients with appendicitis who were admitted to St. Elizabeth's Medical Center of Boston and found that the combination of history and physical examination has withstood the test of time. We found that advancing age, duration of symptoms for 36 or more hours, white blood cell count, shift left in white blood cell count, and fever were significantly related to severe appendicitis. An abnormal plain film was a marker if fever coexisted.
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Affiliation(s)
- Hassan Y. Tehrani
- Department of Surgery, Division of General Surgery, St. Elizabeth's Medical Center of Boston, Boston, Massachusetts
| | - James G. Petros
- Department of Surgery, Division of General Surgery, St. Elizabeth's Medical Center of Boston, Boston, Massachusetts
| | - R. Ravi Kumar
- Department of Surgery, Division of General Surgery, St. Elizabeth's Medical Center of Boston, Boston, Massachusetts
| | - Quyen Chu
- Department of Surgery, Division of General Surgery, St. Elizabeth's Medical Center of Boston, Boston, Massachusetts
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Abstract
A complete understanding of the anatomy, pathophysiology, and presenting signs and symptoms of appendicitis, combined with a thorough history and physical examination, will be the most important factors in allowing the practicing emergency physician to make the correct diagnosis of acute appendicitis. For patients in which the diagnosis is less clear or for patients in high-risk groups (extremes of age, pregnant women, and immunocompromised patients) additional diagnostic testing, usually US or CT, and early surgical consultation are recommended.
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Affiliation(s)
- C S Graffeo
- Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, USA
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Rusnak RA, Borer JM, Fastow JS. Misdiagnosis of acute appendicitis: common features discovered in cases after litigation. Am J Emerg Med 1994; 12:397-402. [PMID: 8031420 DOI: 10.1016/0735-6757(94)90047-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
To identify differences between correctly diagnosed appendicitis and misdiagnosed cases that resulted in litigation between 1982 and 1989 retrospective review of malpractice claims was conducted. A total of emergency department (ED) charts at the time of the initial ED visit were reviewed and compared with 66 concurrent controls. Missed cases appeared less acutely ill, had fewer complaints of right lower quadrant pain, received fewer rectal examinations, received intramuscular (IM) narcotic pain medication for undiagnosed abdominal pain or symptoms, and more often received an ED discharge diagnosis of gastroenteritis. Misdiagnosed patients had a 91% incidence of ruptured appendix, more extensive surgical procedures, and more postoperative complications. Data were analyzed using the Pearson's chi 2 Test, Mann-Whitney U Test, and stepwise discriminant analysis. Significance was defined as P < or = .05. Misdiagnosis of acute appendicitis is more likely to occur with patients who present atypically, are not thoroughly examined (as indexed by documentation of a rectal examination), are given IM narcotic pain medication and then discharged from the ED, are diagnosed as having gastroenteritis (despite the absence of the typical diagnostic criteria), and with patients who do not receive appropriate discharge or follow-up instructions.
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Affiliation(s)
- R A Rusnak
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis MN 55415
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Abstract
The incidence of acute appendicitis in the elderly will continue to increase as the elderly population enlarges. Because appendicitis is much more serious in elderly patients compared to younger patients, the care we render to elderly individuals must be optimal, and recent improvements in care have dropped mortality rates significantly.
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Abstract
Historically, appendicitis in the elderly is associated with higher morbidity and mortality. Ninety-six patients over 60 years of age with appendicitis treated over a 10-year period were reviewed. Only 20% presented classically with anorexia, fever, right lower quadrant pain, and an elevated white blood cell count. One third of the patients had greater than 48 hours delay to admission. Objective diagnostic testing was often confusing and unreliable. At the time of admission, only 51% were diagnosed as having possible appendicitis. Eighty-three percent of our patients underwent surgery within 24 hours, and 72% had frank perforation. Thirty-two percent of those surviving developed complications, and 83% of these patients had perforated appendicitis. Complications were twice as likely in patients with perforation. Despite the relatively high morbidity, there were only four deaths in patients with coexistent carcinoma. Because of the later and atypical presentation of appendicitis in this age group, a high index of suspicion and early operation are important in avoiding perforation and subsequent morbidity.
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Affiliation(s)
- M C Horattas
- Department of Surgery, Akron General Medical Center, Northeastern Ohio Universities College of Medicine, Ohio 44307
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Affiliation(s)
- R D Shamburek
- Department of Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond
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Abstract
Methods used to improve the accuracy of diagnosis of acute appendicitis are reviewed. Laparoscopy, barium enema, ultrasonography and computer assistance have all been shown to improve accuracy, but no one method is of proven superiority. Such diagnostic aids or intensive in-hospital observation must be used to reduce the 15-30 per cent negative laparotomy rate when acute appendicitis is suspected, without increasing the incidence of appendiceal perforation.
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Affiliation(s)
- J Hoffmann
- Department of Surgery D, Glostrup Hospital, University of Copenhagen, Denmark
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